For endoscopic skull base surgery, the application of an antibiotic for 24—48 hours was sufficient, independently from intraoperative CSF leakage [ ]. If antibiotics are part of the following treatment concept of the original, e. The vast majority of authors perform perioperative antibiosis in the context of duraplasty [ ].
It occurs as intravenous dose as long as nasal packings or lumbar drainage are in situ and should be sufficiently effective against Staph.
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There is no proven evidence confirming the benefit of long-term antibiosis going beyond this period of time [ ]. Reports about complication-free endonasal duraplasties with use of nasal packing without antibiotic therapy have been published [ ]. The majority of the studies as well as a current meta-analysis could not reveal an advantage regarding the reduction of intracranial infections or mortality.
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In contrast, the risk of a selection of resistant bacteria increases [ ], [ ]. In summary, it is also true for endonasal endoscopic sinus surgery that a routinely performed antibiotic therapy is not required but a critical weighing up of the benefits and risks with consideration of well-known influencing factors. Prophylactic antibiotic treatment that is indicated in individual cases is usually applied only for a short period of time.
Today, endoscopy is considered as standard in diagnostics and therapy of most diseases of the paranasal sinuses [ 19 ], [ ], [ ], [ ], [ ]. The multitude of available endoscopes and technical equipment allows a diagnostic and therapeutic approach to nearly all regions. A previously performed investigation on the spatial handling security, the endoscope was at least equal with the binocular surgical microscope [ ]. However, a more recent study revealed that the surgical exactness of performing different tasks was higher in unexperienced neurosurgeons using a microscope in comparison to using an endoscope.
More experienced surgeons had an equal failure rate. The velocity in beginners and experienced surgeons was higher when they used a microscope [ ]. Due to important technical development, the endoscope compared to the microscope is superior as optical device. It combines a very good overview due to wide angle technology with a very good detailed view due to HD technology, even in bloody sites. It allows looking around the corner by using angular optics under ergonomically favorable conditions due to video endoscopy.
Only by means of endoscopy, a four-hand technique is possible.
Even for education, training, and the control of surgical steps the endoscopic technique has more advantages. Even supervision of surgery is possible by means of teleconferencing [ ]. If older systems are used, video endoscopy provides poorer images than the direct view through the endoscope [ ]; the time-loss in a nasal training model touching different hidden spots was increased [ ]. The use of modern HD video endoscopy leads to a significantly better image quality in comparison to older systems.
Based on this fact, medico-legal consequences must be considered. It is a major obligation of a hospital to provide the instruments that correspond to actual international standards [ 10 ]! In current surgery manuals, the application of the surgical microscope is no longer mentioned, apart from one exception [ ].
The surgical technique with simultaneous use of microscope and endoscope, as it had been promoted by Wolfgang Draf for several years, was left by the majority of the surgeons. Generally, the use of a microscope further leads to a more severe traumatization in the area of the nasal entry and the turbinates. Thus the application of the microscope alone can no longer be recommended. The concept of functional endoscopic sinus surgery is based on the publications of Messerklinger [ ], [ ], [ ], according to which disturbed mucociliary clearance and narrow areas of the ostiomeatal unit are described as origin of recurrent and chronic rhinosinusitis.
Promoters of MIST consider it sufficient to enlarge the narrow clefts of ethmoid [ ], [ ], [ ], [ ], [ ], [ ], even in cases of more extended disease. An essential part of the MIST concept is the use of the shaver that should increase the surgical precision. The single steps encompass: uncinectomy with exposure of the natural maxillary ostium, removal of the postero-medial wall of the agger nasi cells, if needed also mini-trepanation of the frontal sinus with rinsing, opening of the bulla ethmoidalis, repositioning of the middle turbinate medialization is not defined in detail , if needed opening of the posterior ethmoid, if needed removal of polyps before the sphenoid ostium, if needed dilatation of the access of the sphenoid sinus.
This concepts seems to be inconsistent in so far, as optionally a significant extension of the surgical measures is offered, the shaver as integral part has not proven to lead to superior results, and in contrast to the alternative contemporary concept of avoiding nasal packing the local insertion of nasopore, gel film, or merogel is performed. So there is no evidence for the superiority of MIST in comparison to other surgical concepts. Today, FESS is the gold standard of surgical therapy of chronic rhinosinusitis [ 19 ], [ ], [ ], [ ].
The extent of appropriate surgery, however, is still variable in actual concepts of FESS — the respective differences are not highlighted by specific evidence [ ]. Apparently, CRS is caused by multiple factors and includes many subtypes, which is extensively described by Bachert in his complementary review to this present paper [ ].
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Generally, variations of microanatomy are not considered as the main cause of diffuse CRS [ 19 ], however, in single cases they may be meaningful, for example in cases of circumscribed forms of chronic rhinosinusitis [ 19 ], [ ]. In recurrent acute rhinosinusitis, anatomical variations such as a narrow infundibulum ethmoidale, spacious infraorbital cells play a disease-promoting role [ ].
Also the importance of the mucociliary clearance regarding the results after endonasal sinus surgery is not definitively clarified [ ]. Whereas current investigations found a significant correlation between obstruction of the ostiomeatal unit and a disease of the maxillary, anterior ethmoid, and frontal sinus in CRSsNP patients or a non-eosinophilic CRS, this could not be revealed for eosinophilic chronic rhinosinusitis or CRSwNP [ ], [ ], [ ]. The creation of a large maxillary window did not influence the stenosis of the maxillary ostium caused by recurrent polyps [ ]. This leads to a surgical concept that includes the creation of larger openings maxillary sinus: maximal middle meatal antrostomy, if needed variations of medial maxillectomy, canine fossa trephine approach; frontal sinus: type III in cases of advanced disease high CT score according to Lund-Mackay or Kennedy despite maximal medical therapy; eosinophilic CRS; bronchial asthma; analgesics intolerance; recurrence disease and thus finally a unique cavity without relevant separations that can be accessed for local anti-inflammatory therapy [ ], [ ], [ ], [ ], [ ].
On the other hand, polyps should be removed consequently down to the basal membrane [ ] because the eosinophils are located at the base of the polyps [ ] and residual polyps contain CD8-positive memory cells [ ], [ ], [ ]. Especially for therapy of advanced diseases, usually surgery and drug therapy have to be combined whereby the topical therapy plays a crucial role because of effectiveness- and safety reasons [ ]. A topical therapy of the paranasal sinuses is only sufficiently possible if open accesses to the paranasal sinuses are present which presupposes surgery [ ], [ ].
The topical therapy succeeds the better, the more those accesses are opened [ ].
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The maxillary ostium should have a width of at least 4—5 mm [ ]. The frontal sinus can be best treated topically by application of type III drainage [ ]. Nasal rinsing is better able to reach the paranasal sinuses compared to sprays, drops, or inhalations [ ], [ ]. The promoters of an extensive and radical surgical technique invoke a series of studies that report on very good results either in comparison with conservative surgery or in cases of therapy refractory rhinosinusitis after failed previous surgery — however, the majority of the respective literature reports are based on retrospective case series only:.
Even one prospective randomized study could prove the superiority of more radical procedure in CRSwNP: symptoms, postoperative consumption of drugs were significantly lower, the degree of swelling in CT scans and the endoscopy score were lower than in patients who underwent surgery also via the inferior meatus in addition to maxillary sinus surgery [ ]. Therapeutic results in therapy-refractory rhinosinusitis with special consideration of the frontal sinus: comparing frontal sinus drainage type III to frontal sinus drainage type IIa, the revision rate after 12 months was 7 vs. When frontal sinus surgery was performed in cases of clinically evident involvement of the frontal sinus in CRS, the revision rate amounted to Better therapeutic results were obtained after pro-active partial resection of the middle turbinate [ ], [ ], [ ].
On the other hand, radical endonasal surgery according to Denker does not seem to lead to empty nose syndrome or ozaena [ ], [ ].
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Neither has empty nose syndrome been described for frontal sinus drainage type III [ ], [ ], [ ], [ ]. There is no universal classification of sinus operations even if it was desirable, already with regard of quality management [ ]. Different classifications have been elaborated, among them especially the classification of frontal sinus drainages according to Draf has been widely accepted. To describe the extent of CRS, there are different classification systems.
The following three are the most widespread, and in combination they allow at the same time an exhaustive description of the disease. For each of the paranasal sinuses maxillary sinus, anterior ethmoid, posterior ethmoid, frontal sinus, and sphenoid sinus scores 0—2 are given for each side separately:. Hence, these score may achieve values between 0 and An average value in healthy people amounts to about 4. Regarding the technique of endonasal endoscopic sinus surgery, there are a series of current and well established monographs that will be mentioned in this section [ 83 ], [ ], [ 12 ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ], [ ] [ ], [ ], [ ], [ ], [ ], [ ].
They are not the topic of this review. Usually, a patient is focused on his disease and is primarily interested in the possibly curative treatment, followed by aspects of function and post-therapeutic morbidity as well as finally aesthetic reflections. Any patient will sum up all the aspects mentioned when he chooses therapy and also the surgical approach following intensive counselling. Up to now it could not be satisfactorily clarified if and how it may be possible to find out before surgery which patient should undergo which type of surgery with the best cost-benefit ratio.
It is hard to predict, for which patient a small intervention is sufficient, and when extensive surgery is justified and necessary. According to the general opinion, minor disease requires only circumscribed surgery.
The extent of the intervention increases with the extent of the disease, especially in CRS. Apart from variations of the access to treat isolated diseases of the sphenoid sinus, nearly every sinus surgery starts with uncinectomy, at least in patients who had not undergone previous interventions. Only uncinectomy allows the precise identification of the natural maxillary ostium and the exposure of the infundibulum ethmoidale as natural drainage pathway of the anterior ethmoid and the frontal sinus.
If needed, surgical measures at the nasal septum and the middle turbinate may precede, in rare cases also at the inferior turbinate in order to achieve sufficient space to access the middle meatus. Uncinectomy may be performed in anterior-posterior direction or retrograde from posterior to anterior. Using the anterior-posterior technique, the uncinate process is incised near the attachment at the lateral wall.
The incision is extended in superior and inferior direction, expanding the infundibulum ethmoidale, which is located behind it, by medial movement of the instrument at the same time. After removal of the mobilized part of the uncinate process, the remaining horizontal part can be taken from its mucosal pouch and resected and the surplus mucosa is removed. Thus, the natural maxillary ostium is completely exposed and can be examined with regard to its size and possible mucosal swellings.
Endoscopy of the maxillary sinus is partially possible. Up to this point, the mucosa of the maxillary ostium is still intact. Regarding the posterior-anterior technique, the uncinate process is incised starting at the free edge from dorsal in anterior direction or punched out and from there the horizontal part is detached and the surplus mucosa is removed. The swing door technique implies the additional incision and removal of the middle part of the uncinate process already at the beginning [ ].
Complete uncinectomy with removal of the cranial part usually opens the view to the agger nasi cell. A typical surgical risk with subsequent failure of the surgery is missing the natural ostium because of leaving a too big part of the uncinate process behind [ 16 ], [ 17 ] occurring in 42 of cases in anterior-posterior technique, [ ]. The anterior-posterior technique bears the specific additional risk of penetrating the lamina papyracea which is much smaller in the posterior-anterior technique [ ], [ ].
The basic principles of maxillary fenestration and middle meatal antrostomy were formulated many years ago and have not changed since then [ ], [ ]. First objective of maxillary sinus surgery is the precise identification and assessment of the natural ostium. This requires the use of optics with an angulated view [ ]. Depending on the individual anatomy and type and extent of the disease, adapted extension is performed. The optimal size for the middle meatal antrostomy is unclear [ ], [ ], [ ].
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There are recommendations to preserve sufficiently sized natural ostia in certain cases [ ], [ ], [ ] e. A rough classification differentiates between preservation grade 1 , moderate, and extended maximal enlargement grade 2 and 3, respectively; [ 83 ], [ ]. A moderate enlargement for example is recommended when surgical measures in the maxillary sinus are necessary, like suction of secretion or removal of mucosal structures [ 83 ], [ ]. In cases of severe disease CRSwNP, recurrences, eosinophilic rhinosinusitis, allergic fungal sinusitis usually a maximal enlargement of the maxillary sinus via the middle meatus is recommended [ 1 ], [ ], [ ], [ ], [ ], also in order to create favorable conditions for postoperative rinsing whereby the maxillary opening should be at least 4—5 mm [ ].
The permanent opening of the maxillary sinus is bigger if the natural ostium was additionally enlarged intraoperatively after uncinectomy [ ], [ ].